De-Escalating Treatment Can Be Detrimental
Although it may be tempting to de-escalate chemotherapy in frail patients, Dr Falandry said de-escalation is not a good option.
In a phase 2 trial, Dr Falandry and colleagues found that patients with a high GVS had worse outcomes with single-agent carboplatin than with regimens containing carboplatin and paclitaxel.6
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The trial included 120 patients with stage III-IV ovarian, fallopian tube, or primary peritoneal cancer. The patients’ median age was 80 (range, 70-94) years, and they all had a GVS of 3 or higher.
The patients were randomly assigned to receive 6 cycles of carboplatin plus paclitaxel every 3 weeks (control arm), single-agent carboplatin every 3 weeks, or weekly carboplatin plus paclitaxel on days 1, 8, and 15.
The trial was stopped early because patients in the single-agent arm had significantly worse survival than patients in the other arms. The median overall survival was not reached in the control arm, 7.4 months in the carboplatin-alone arm, and 17.3 months with weekly combination therapy. The median progression-free survival was 12.5 months, 4.8 months, and 8.3 months, respectively.
Assessing Fitness for Sequential Interventions
Dr Falandry also reviewed a position paper she coauthored that outlines a framework for the care of older patients with ovarian cancer.7 The framework is based on a set of general principles:
- Older patients have a higher risk of perioperative mortality and morbidity that can impact the dose intensity of subsequent chemotherapy, so decisions about surgery should be based on laparoscopic assessment whenever possible.
- Patients older than 75 years with stage IV ovarian cancer, stage III ovarian cancer and evolving comorbidity, or a GVS of 3 or higher do not benefit from upfront surgery.
- Upfront surgery exposes patients to higher risks of delayed chemotherapy or reduced treatment intensity.
- Preoperative chemotherapy can decrease surgical complexity and permit interventions for geriatric covariates to reduce surgical risk.
Dr Falandry and her coauthors also identified 4 decisional “nodes” for multidisciplinary care planning: confirm diagnosis and extent of disease, assess resectability, determine operability, and decide on adjuvant and maintenance treatment.
In closing, Dr Falandry emphasized that a patient’s age should not delay diagnostic procedures or referrals to expert centers. She added that hospitals and health systems should proactively avoid such delays, be “age-friendly,” and promote multidisciplinary discussions and fluidity between treatment sequences.
Disclosures: Dr Falandry disclosed relationships with Leo Pharma, Pfizer, MSD Oncology, AstraZeneca, Janssen Oncology, Novartis, Chugai Pharma, Astellas Pharma, Bristol Myers Squibb, GlaxoSmithKline, Clovis Oncology, Lilly, and Eisai.
References
1. Falandry C. How to optimise older patients for cancer treatments? Managing the consequences of cancer treatments. Presented at the ESMO Gynaecological Cancers Congress; June 17-18, 2022.
2. Urban RR, He H, Alfonso R, Hardesty MM, Gray HJ, Goff BA . Ovarian cancer outcomes: Predictors of early death. Gynecol Oncol. 2016;140(3):474-480. doi:10.1016/j.ygyno.2015.12.021
3. Thrall MM, Goff BA, Symons RG, Flum DR, Gray HJ. Thirty-day mortality after primary cytoreductive surgery for advanced ovarian cancer in the elderly. Obstet Gynecol. 2011;118(3):537-547. doi:10.1097/AOG.0b013e31822a6d56
4. Falandry C, Weber B, Savoye AM, et al. Development of a geriatric vulnerability score in elderly patients with advanced ovarian cancer treated with first-line carboplatin: A GINECO prospective trial. Ann Oncol. 2013;24(11):2808-2013.
5. Falandry C, Pommeret F, Gladieff L, et al. Validation of the geriatric vulnerability score in older patients with ovarian cancer: An analysis from the GCIG-ENGOT-GINECO EWOC-1 study. Lancet Healthy Longevity. 2022;3(3):e176-e185. doi:10.1016/S2666-7568(22)00002-2
6. Falandry C, Rousseau F, Mouret-Reynier M-A, et al. Efficacy and safety of first-line single-agent carboplatin vs carboplatin plus paclitaxel for vulnerable older adult women with ovarian cancer. A GINECO/GCIG randomized clinical trial. JAMA Oncol. 2021;7(6):853-861. doi:10.1001/jamaoncol.2021.0696
7. Bengrine L, Bakrin N, Rousseau F, Lavoué V, Falandry C. Multi-disciplinary care planning of ovarian cancer in older patients: General statement—a position paper from SOFOG-GINECO-FRANCOGYN-SFPO. Cancers. 2022;14(5):1295. doi:10.3390/cancers14051295
